Evaluation of Functional Recovery Following Thrombectomy in Patients With Large Vessel Occlusion and Prestroke Disability

Sprügel, Maximilian I.; Sembill, Jochen A.; Kremer, Svenja; Gerner, Stefan T.; Knott, Michael; Hock, Stefan; Engelhorn, Tobias; Dörfler, Arnd; Huttner, Hagen B.; Schwab, Stefan

doi:10.1001/jamanetworkopen.2022.27139

JAMA Netw Open

2022

DOI: 10.1001/jamanetworkopen.2022.27139

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Evaluation of Functional Recovery Following Thrombectomy in Patients With Large Vessel Occlusion and Prestroke Disability

Maximilian I. Sprügel

Jochen A. Sembill

Svenja Kremer

et al.

Abstract: IMPORTANCEIt is uncertain whether thrombectomy is associated with benefits in patients with prestroke disability. OBJECTIVE To evaluate the use of thrombectomy for patients with large vessel occlusion and prestroke disability. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients with large vessel occlusion stroke and prestroke disability (modified Rankin Scale score, 3 or 4) admitted to a single tertiary care center between

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2024

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Cited by 4 publications

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IV Thrombolysis for Acute Ischemic Stroke with Unknown Onset in Patients on Oral Anticoagulation

Macha,

Sembill,

Muehlen

et al. 2024

Cerebrovasc Dis

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Introduction IV-thrombolysis is established in the unknown or extended time window based on multimodal imaging. Further, increasing evidence exists regarding IV-thrombolysis in patients on oral anticoagulation including direct oral anticoagulants (DOAC). However, data on IV-thrombolysis in ischemic stroke patients on oral anticoagulation with unknown time of stroke onset is sparse. Methods This study bases on the longitudinal cohort study Stroke Research Consortium in Northern Bavaria (STAMINA; ClinicalTrials.gov Identifier: NCT04357899). Acute ischemic stroke patients treated with iv-thrombolysis (IVT) in the unknown or extended time window from January 2015 to December 2019 were included. Patient selection based on multimodal CT or MRI. Patients on oral anticoagulation (vitamin-K antagonist (VKA) or DOAC within 48 hours) were eligible for IV-thrombolysis based on INR-measurement (VKA) or plasma levels (DOAC) according to an institutional protocol. Primary outcomes were the incidence of any and symptomatic intracranial hemorrhage. Results Of 170 ischemic stroke patients treated with IV-thrombolysis in the unknown or extended time window, 151 had no oral anticoagulation at stroke onset and 19 were on oral anticoagulation (6 on vitamin-K antagonist (VKA) and 13 on direct oral anticoagulant (DOAC)). The risk of symptomatic ICH according to ECASS II criteria was similar between the patients with and without oral anticoagulation (1 (5.3%) vs. 4 (2.7%); p=0.453). After adjustment for confounding factors pre-medication with oral anticoagulation was not associated with symptomatic ICH (aOR 1.02 (0.09 – 11.02); p=0.988). Conclusion IV-thrombolysis for ischemic stroke with unknown onset appeared safe in selected patients on oral anticoagulation with both DOAC and VKA.

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IV Thrombolysis for Acute Ischemic Stroke with Unknown Onset in Patients on Oral Anticoagulation

Macha,

Sembill,

Muehlen

et al. 2024

Cerebrovasc Dis

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Endovascular Thrombectomy in Patients With Preexisting Disability: A Review

Wechsler,

Leslie‐Mazwi,

Mistry

2024

SVIN

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Endovascular mechanical thrombectomy (EVT) drastically reduces disability after acute ischemic stroke due to large‐vessel occlusion, but only a small proportion of patients with stroke are eligible for this powerful treatment. Several ongoing studies are aiming to expand the indications for EVT to further reduce disability after acute ischemic stroke for a larger proportion of patients suffering from large‐vessel occlusion stroke. Patients with preexisting disability, comprising ≈30% of all patients with acute ischemic stroke, were universally excluded from the landmark clinical trials that established EVT efficacy. These patients disproportionally suffer from accumulated disability after stroke, with substantial societal and economic impact. Further, there is significant heterogeneity in current practice of EVT among patients with preexisting disability. Establishing evidence‐based acute stroke treatments for this population is a priority. In this narrative review, we summarize the current literature regarding EVT in patients with preexisting disability. While doing so, we highlight key concepts regarding statistical analysis and discuss opportunities and challenges for future studies focusing on this vulnerable population.

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Endovascular thrombectomy in patients with anterior circulation stroke: an emulated real-world comparison

Sembill,

Sprügel,

Haupenthal

et al. 2024

Neurol. Res. Pract.

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Background Endovascular thrombectomy (EVT) has been proven effective in anterior circulation stroke due to large vessel occlusion (LVO). However, translation from randomized clinical trials (RCTs) with highly selected patients to real-world requires confirmation, particularly to identify associations outside of strict selection criteria. Aims This study aims to compare functional outcomes after EVT in real-world with those reported in RCTs, and to identify associations with functional outcome after EVT outside RCT-criteria. Methods This study analyzed longitudinal German real-world data from the Stroke Research Consortium in Northern Bavaria (STAMINA) cohort from January, 2015 to June, 2019. We conducted a trial emulation, comparing patients with anterior circulation stroke and LVO meeting selection criteria for RCTs investigating EVT (1) predominantly within 6 hours with those from HERMES meta-analysis, and (2) within 6-24 hours with those from AURORA meta-analysis. We (3) analyzed treatment effects of EVT and association with functional outcome in patients treated outside RCT criteria. Results Of 598 patients, 281 (47.0%) met RCT-criteria for treatment within 6 hours (hereinafter STAMINA-HERMES), 74 (12.4%) met RCT-criteria for treatment within 6–24 hours (STAMINA-AURORA), and 277 (46.3%) patients received EVT outside RCT-criteria. We observed no difference in rates of functional independence or mortality, comparing STAMINA-HERMES with HERMES meta-analysis (mRS 0-1: n=120/281 [43%] vs. 291/633 [46%], p=0.36; mortality: n=34/281 [12%] vs. 97/633 [15%], p=0.20), and STAMINA-AURORA with AURORA meta-analysis (mRS 0-1: n=26/74 [35%] vs. 122/266 [46%], p=0.10, mortality: n=10/74 [14%] vs. 45/266 [17%], p=0.48). Patients treated outside RCT-criteria had worse outcome (mRS 0-1: n=38/277 [14%], mortality: n=90/277 [32%], both p<0.001); possibly driven by pre-existing functional dependence (n=172/277 [62%]). Compared to matched controls, EVT outside of RCT-criteria was associated with lower mortality (absolute treatment effect: -14%, 95% Confidence Interval [CI] -23 to -5, p<0.01), but not with recovery to functional independence or premorbid functional status (treatment effect: 4%, CI -4 to 11, p=0.34), which was associated with lower NIHSS (Odds ratio [OR] 0.86, CI 0.80-0.92, p<0.001) and age (OR 0.95, CI 0.93-0.98, p=0.002). Conclusions Translation of EVT outcomes reported in RCTs into real-world is possible, however, almost half of patients did not meet trial criteria. Identification of patients who functionally benefit from frequently performed EVT outside RCT-criteria requires further investigation. Trial registration Clinicaltrials.gov, NCT04357899.

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Evaluation of Functional Recovery Following Thrombectomy in Patients With Large Vessel Occlusion and Prestroke Disability

Cited by 4 publications

References 47 publications

IV Thrombolysis for Acute Ischemic Stroke with Unknown Onset in Patients on Oral Anticoagulation

IV Thrombolysis for Acute Ischemic Stroke with Unknown Onset in Patients on Oral Anticoagulation

Endovascular Thrombectomy in Patients With Preexisting Disability: A Review

Endovascular thrombectomy in patients with anterior circulation stroke: an emulated real-world comparison

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